Travel Alert: Same Name, Different Drug

The Institute for Safe Medication
Practices has received a number
of reports involving brand name
medications that may contain different
active ingredients in another country.

In one report, a patient was prescribed
Dilacor
XR (diltiazem extended-release)
120 mg daily for hypertension. While traveling
to Serbia, he ran out of medication.
A Serbian pharmacist filled the prescription,
but he actually dispensed digoxin
0.25 mg because, in Serbia, Dilacor is a
brand name for digoxin. The patient
did
not notice the change in tablet
strength,
so he continued to take the medication
for 3 days upon return to the United
States. He took extra doses each day (2-3
tablets), however, because he felt that his
blood pressure medication was not working.
By the third day, the patient experienced
signs of digoxin toxicity, including
nausea, vomiting, headaches, and chest
pain worsened by exertion. He went to an
emergency department and was admitted
for monitoring and treatment with
Digibind (digoxin immune FAB).

In another case, a hospitalized patient
developed gastrointestinal (GI) bleeding,
and the medical team was trying to
determine
the cause. A pharmacy student
on the team was asked to find out
what ?Cartia? was, since the patient had
apparently
been taking that medication
prior to admission. The student found
that several Web sites, as well as Micromedex,
described Cartia as a 100-mg,
enteric-coated tablet of aspirin. When
the student reported this information to
the team, a decision was made to discontinue
the drug, as aspirin can cause
GI bleeding. Fortunately, a medication
error was averted when it was discovered
that the patient was actually taking
Cartia XT (diltiazem in the United States),
which is bioequivalent to Cardizem CD,
to treat hypertension and angina.

Cartia is a trademark for enteric-coated
aspirin in New Zealand and Australia.
This product can be purchased over the
Internet in the United States, however,
and both products could be considered
heart medications, increasing the risk
of error. If a patient
taking Cartia XT
searches the Web and finds that ?Cartia?
is available without a prescription and
inexpensive (one site advertised 28 tablets
for $1.94 in US dollars), a medication
error could occur. Confusion also could
exist among physicians trained outside
the United States or patients who travel
between the United States and New
Zealand or Australia.

Finally, the trademark Entex LA is
used for 2 different products in the
United States and Canada. In the United
States, Andrx Pharmaceuticals markets
a capsule formulation of Entex LA that
contains phenylephrine hydrochloride
(30 mg extended-release) and guaifenesin
(400 mg immediate-release). In
Canada, Purdue
Pharma Canada supplies
Entex LA as a tablet that contains
pseudoephedrine (120 mg) and guaifenesin
(600 mg). Compounding
the confusion,
the indicated adult dose for each
product is one tablet every 12 hours.

Safe Practice Recommendations

Be cautious of drug information obtained
only from the Internet. The Internet
knows no national boundaries, so
information?even drug names?found
may be inaccurate and/or not applicable
to health care in the United States.
Always question patients on the reason
they are taking their medications so as
not to rely solely on drug references.
Remind patients
when they travel to
carry an adequate supply of medications
and a list by generic and brand name.
Those needing a temporary supply while
overseas should confirm that the correct
drug has been dispensed, as brand
name products may contain different
active ingredients in different countries.